Evidence-based Screening Tools and Beyond

1. Evidence-based Screening Tools and Beyond Kris Carrillo*, LISW Envision NM, UNM Department of Pediatrics Mary Ramos, MD, MPH – NM DOH, UNM Department of Pediatrics * With help from Dan Rifkin, MD and others at Envision NM

2. Objectives • Understand the distinction between Screening and Assessment • Recognize screening questions for substance abuse, depression, and anxiety as they appear in the Student Health Questionnaire • Understand the next steps involved when patient screens positive

3. Screening Tools • Identify those at higher risk • Sort out apparently well persons who may have a disease from those who probably do not • Are not diagnostic; they help to quickly identify those who need assessment

4. What Medical Conditions are Suitable for Screening? • How great a burden is caused by the disease? • How effective is the treatment for the condition? • (Is early treatment effective?) • How good is the screening tool? • Sensitivity, specificity • Cost, safety, acceptability

5. A Screening Tool Can Be.. • A medical history question: “Do you smoke?” • Part of the physical exam: clinical breast exam • A laboratory test: stool guaiac test • A procedure: sigmoidoscopy

6. Screening tools should be.. • Highly sensitive, to pick up most cases • Low in specificity, which will result in some false positive results • Inexpensive • Safe • Well accepted

7. Why Screen for Adolescent Behavioral Health Problems? • Prevalent: by age 18, 20% of youth have experienced at least one episode of depression. • Depressed youth are at increased risk of suicide, school failure, and substance abuse. • Treatable! • Depression, anxiety disorder, substance abuse are all treatable.

8. Youth Depression Epidemiology • Depression is one of the most serious and common problems encountered by youth of all ages. • 2 million U.S. teens suffer from clinical depression, yet most undiagnosed and untreated. • As many as 1 in 33 children (3%) may have clinical depression • More than 1 in 8 adolescents (12.5%) may have clinical depression

9. Why Screen for Adolescent Behavioral Health Problems? • In the US, fewer than half of the youth who meet criteria for mental health disorders receive treatment for those disorders. • Treatment often not begun until early adulthood. • The delay in diagnosing and treating mental health disorders in adolescents has lead to increased focus on screening and improving quality of treatments in primary care settings.

10. How Common is Youth Suicide? • Suicide is 3rd leading cause of death in 11-18 year olds. • 90% of teens who die by suicide suffer from a diagnosable mental illness at the time of their death.

11. How Common is Youth Suicide? • Depression is the diagnostic category most often associated with suicidal ideation and behavior in teenagers (Brent &Poling, 1997). • Psychiatric symptoms developed more than one year prior to death in 63% of adolescent suicides (2003 data).

12. Screens Embedded in SHQ • Depression, Anxiety, and Sleep • Suicidality, Safety, Violence, Abuse • Substance Abuse: CRAFFT • School: learning/performance; skipping/suspension • Supervision • Relationships: Family, Friends/Peers • Other Psychosocial Stressors: moves; work • Sex: STD and Pregnancy Risk • Health: eating problems, weight, exercise, tobacco • Medical: e.g. Diabetes, Asthma, Seizures

13. The CRAFFT • A substance abuse screening test that has been validated for use with adolescent patients • The CRAFFT consists of 6 items; if any two are positive, it is a positive screen • Arch Pediatr Adolesc Med. 2002;156:607-614

14. CRAFFT • Have you ever ridden in acar driven by someone (including yourself) who was “high” or had been using alcohol or drugs? • Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in? • Do you ever use alcohol or drugs while you are by yourself, alone? • Do you ever forget things you did while using alcohol or drugs? • Do your family or friends ever tell you that you should cut down on your drinking or drug use? • Have you ever gotten into trouble while you were using alcohol or drugs?

15. How do I use the CRAFFT? • It is simple. If a student answers “Yes” to any 2 of the questions, it is a positive screen. • A positive screen indicates to providers that an assessment is needed to determine possible alcohol or drug problems.

16. What is bottom line? • The CRAFFT is valid and quick screening tool for adolescents • Because it screens for both alcohol and other drug problems simultaneously, it is especially handy for providers • A positive CRAFFT means the student should be assessed for alcohol/drug abuse or dependence

17. Screening for Depression • The US Preventive Services Task Force now advises primary care clinicians to screen adolescents for depression • provided there is a system of care to confirm diagnosis and initiate treatment • Pediatrics. 2009;123(4):1223-1228.

18. The Patient Health Questionnaire (PHQ-2) • A depression screening tool that has been validated for use with adolescent patients. • 2 items • Depressed Mood • Anhedonia • Pediatrics. 2010; 125(5):e10971103

19. The PHQ-2 Over the last 2 weeks, how often have you been bothered by any of the following symptoms? (A) Little interest or pleasure in doing things (B) Feeling, down, depressed, or hopeless Not at all Several days More than half the days Nearly every day Pediatrics. 2010; 125(5)

20. SHQ version • Have you had difficulty finding any activities you enjoy in the past two weeks? • Do you often feel sad or down, as though you have nothing to look forward to?

21. Screening for Anxiety • Do you often worry about or feel like something bad might happen? • Are you often tense, stressed out, and/or have difficulty relaxing?

22. Determining Risk on the SHQ(Using Your Clinical Judgment) • Interpret student responses to SHQ items by asking follow-up questions to clarify risk. • Use the Low, Medium and High risk boxes on the SHQ • Decide what action is needed based upon risk determination

23. Roles • PCPs share with BH providers the responsibility of student risk factor identification • SBHC team members work together to ensure that needed action is taken based upon risk factor determination

24. Guidelines • Not “finders keepers” • No hard and fast rules • Err on the side of caution • Determine risk using clinical judgment that balances potentially problematic risk factors with understanding of resilient and protective factors students report.

25. Structure of the SHQ • Any “yes” answer in any section requires further questioning by the provider • Follow-up questions will clarify whether or not a risk actually exists, and to what degree

26. Framework: Prioritize Risks • What risks constitute an emergency? • What risks require same day follow-up (such as further interview or assessment tool administration)? • How do you decide?

27. What additional factors might raise a low-risk to a medium-risk? • Substance Abuse Issues • Eating-related issues • Family/Home Issues • Sexuality Issues/Early sexual activity • Violence (incl. abuse) section • Exclusion/Victimization • Discrimination • Enculturation issues

28. Determine Overall Risk: Sum of the Parts • Comprehensive risk determination requires perspective gained from reviewing risk determined for each section of the SHQ.

29. Follow-Up Assessment Tools • PHQ-9 • SCARED

30. Feeling Over Your Head? Resources: Telepsychiatry/Psychopharm Consultation CRCBH Calling your SMHA for guidance QI with Envision NM

31. Additional Resources • TIP 31: Screening and Assessing Adolescents for Substance Use Disorders, at http://store.samhsa.gov/product/SMA09-4079 • Screening and Treating Adolescents for Substance Use Disorders: KAP Keys for Clinicians Based on TIPS 31 and 32 http://store.samhsa.gov/product/KAPT312

32. Additional Resources • National Institute on Drug Abuse Research Monograph Series. Adolescent Drug Abuse Clinical Assessment and Therapeutic Interventions Archives http://archives.drugabuse.gov/pdf/monographs/download156.html